| Available Plans: | Widget Beacon 1000 |
| Plan Rates: | |
| Individual: | $0.01 |
| Individual + Spouse: | $0.01 |
| Individual + Child(ren): | $0.01 |
| Family: | $0.01 |
| OUTPATIENT BENEFITS | |
Physician Office - 5 visits per person per year - 10 visits per family | $100 |
Health Screening - 3 visits per person per year | $100 |
Diagnostic/X-Ray/Labs Test - 3 test per person per year - 6 per family | $100 |
Routine Well Child - Limited to 6 visits within first 12 months of child's life | $100 |
| HOSPITAL BENEFITS | |
Emergency Room Accident Benefit - 1 visit per person per year | $100 |
Hospital Admission Benefit - Limit 2 per year | $1,000 |
Hospital Confinement Benefit - 30 days per occurrence | $1,000 |
Intensive Care Unit Benefit - 15 days per occurrence | $1,000 |
| SURGERY & ANESTHESIA BENEFITS | |
Surgical Benefit Schedule - paid as a percentage of the surgery schedule - no annual or lifetime max | 300% |
Anesthesia Benefit - percentage of the scheduled Surgical benefit amount | 25% |
Ambulatory Surgery Center Benefit - per day | $250 |
| CRITICAL ILLNESS BENEFITS | |
Critical Illness Benefit - Invasive Cancer, Heart Attack, Stroke, Renal Failure, Coronary Bypass & Active Daily Living Deficit | $10,000 |
InSitu Cancer Benefit % | 25% |
| ACCIDENTAL DEATH BENEFITS | |
Accidental Death Benefit | $40,000 |
| DISMEMBERMENT BENEFITS | |
Loss of Both Hands or Both Feet, Loss of Sight in Both Eyes, Loss of One Hand AND One Foot, Loss of One Hand AND Sight in One Eye, Loss of Speech AND Hearing in Both Ears, Loss of Hearing in One Ear, Loss of Thumb AND Index Finger | $20,000 |
Loss of One or More Finger or Toes | $2,500 |
| DISLOCATION AND FRACTURE BENEFIT | |
Dislocation Benefits (All) and Fractures | $1,500 |
Fractures – Other | $1,000 |
| VALUE ADDED BENEFITS | |
Lab & Imaging and Adult Family Wellness Program | INLCUDED |
AmeriDoc Telemedicine Services | INLCUDED |
Patient Advocacy & 24 Hour Nurse Hotline | INLCUDED |
| LIFESTYLE BENEFITS | |
Roadside Assistance Program | INLCUDED |
Movie & Amusement Park Tickets | INCLUDED |
Dining & SHopping Discounts | INCLUDED |
| PRESCRIPTION DRUG COVERAGE | |
Advantage Rx - $10 Generic - $30 Brand Name ($100 Individual - $200 Famliy) | INCLUDED |
| ACCIDENT MEDICAL COVERAGE | |
Accident Medical Coverage – No annual limit, $100 Deductible - Underwritten by Zurich | $2,500 |
* Unless otherwise specified, these items are not insurance. The Value Added Benefit programs except for vision is neither underwritten nor insured by National Union Fire Insurance Company of Pittsburgh, Pa. National Union Fire Insurance Company of Pittsburgh, Pa. assumes no responsibility or liability for any of the listed services, the providers of the services, the quality of the services, the delivery of the services or the outcomes of the services. Questions or concerns about the services should be addressed directly to the providers.The premium rates above include a charge for the Value Added programs and administrative services provided by ADMU Benefits.
BENEFIT DESCRIPTIONS
OUTPATIENT BENEFITS
Physician’s Office Visits Benefit - pays a Per Visit benefit if an Insured Person visits a Physician’s office for treatment of Sickness or Injury. Health Screening Benefit—pays a Per Test amount when an Insured Person undergoes specified routine examinations or other preventive testing. Routine Well-Child Benefit—pays a Per Physician’s Visit amount when an Insured Dependent Child visits a Physician and undergoes physical examination and/or appropriate immunizations during the first 12 months following birth. Emergency Room Accident Treatment Benefits—pays a Per Accident benefit shown when an Insured Person suffers an injury that, within 72 hours of the accident that caused the injury, requires him or her to receive Emergency Treatment in the Emergency Room of a Hospital.Emergency Room Sickness Treatment Benefit—pays a Per Visit benefit when an Insured Person visits the emergency room of a Hospital for Emergency Treatment of Sickness.
Outpatient Diagnostic X-Ray and Laboratory Benefit—pays an Outpatient Diagnostic X-Ray and Laboratory Benefit when an Insured Person visits a Physician’s office or other outpatient setting except an emergency room, and undergoes diagnostic x-ray and/or laboratory tests for treatment of a sickness or injury.HOSPITAL BENEFITS
Hospital Admission Benefit—pays a lump sum Hospital Admission benefit if an Insured Person is admitted as an inpatient to a Hospital for treatment of a sickness or injury. Hospital Confinement Benefit—pays a Daily Hospital Confinement benefit for each day that an Insured Person is charged for a room as an inpatient in a Hospital for treatment of a sickness or injury. Intensive Care Unit Benefit—if benefits have become payable for an Insured Person under the Hospital Confinement benefit, and such Insured Person becomes confined in an Intensive Care Unit, this benefit pays an additional daily Intensive Care Unit benefit for each day the Insured Person is confined in and charged for an Intensive Care Unit.Physician and Hospital Discounts—we offer discounts through the Preferred Provider Network from Beech Street to complement the benefits provided by the Chartis plans. Discounted rates are available at premier physicians, hospitals and medical centers around the country.
SURGICAL/ANESTHESIA BENEFITS
Surgical Benefit - pays a percentage of a “scheduled” amount when an Insured Person undergoes a surgical procedure for the treatment of a sickness or injury. Anesthesia—pays a percentae of a "scheduled" amount for the administration of anesthesia for which a charge is incurred during a covered surgical procedure. Ambulatory Surgical Center Benefit—pays a lump sum benefit if an Insured Person visits an Ambulatory Surgical Center for treatment of a sickness or injury. Accidental Death Benefit—pays a lump sum benefit if an Insured Person suffers an injury that results in death.CRITICAL ILLNESS BENEFITS
Critical Illness Benefit—pays a lump sum benefit upon diagnosis of a specified Critical Illness after a 30 day waiting period. The Company will pay this benefit, subject to the Reduction Schedule and Benefit Payment Conditions listed below, if while this Rider is in force, an Insured Person is first Diagnosed with a Critical Illness by a Physician. Once 100% of the Maximum Benefit Amount has been paid for an Insured Person, coverage terminates and no further benefits are payable for that Insured Person. Benefit Payment ConditionsPayment of benefits upon the first Diagnosis of one of the Critical Illnesses listed below is subject to the following:
1. the Diagnosis is made within the United States;
2. the Diagnosis is made while the Insured Person’s coverage is in force under this Rider; and
3. payment is not precluded by any general or specific exclusion or limitation set forth in this Rider or any failure to meet any condition precedent set out below.
Invasive Cancer - If an Insured Person is first Diagnosed with Invasive Cancer under this Rider, the Company will pay the indicated Benefit Amount shown in the Rider Schedule.
In-Situ Cancer - If an Insured Person is first Diagnosed with In-Situ Cancer under this Rider, the Company will pay the indicated Benefit Amount shown in the Rider Schedule.
Heart Attack - If an Insured Person is first Diagnosed as having suffered a Heart Attack under this Rider, the Company will pay the indicated Benefit Amount shown in the Rider Schedule.
Kidney (Renal) Failure - If an Insured Person is first Diagnosed with Kidney (Renal) Failure under this Rider, the Company will pay the indicated Benefit Amount shown in the Rider Schedule.
Stroke - If an Insured Person is first Diagnosed with having suffered a Stroke under this Rider, the Company will pay the indicated Benefit Amount shown in the Rider Schedule.
ADL Deficit - If an Insured Person is first Diagnosed as having an ADL Deficit under this Rider, the Company will pay the indicated Benefit Amount shown in the Rider Schedule.
Coronary Artery Bypass - If an Insured Person is first Diagnosed,under this Rider, with a condition that necessitates a Coronary Artery Bypass and receives the Coronary Artery Bypass, the Company will pay the indicated Benefit Amount shown in the Rider Schedule.
VALUE ADDED BENEFITS
The added coverages and services are neither underwritten nor provided by National Union Fire Insurance Company of Pittsburgh, Pa., and NUFIC assumes no responsibility or liability for any of the listed services, the providers of the services, the quality of the services, the delivery of the services, or the outcomes of the services. Questions or concerns about the services should be addressed directly to the providers. PRESCRIPTIONS - Prescription Drug Benefit, $10 Generic Only Co-pay program. $250 monthly maximum per person - $500 per family. INSURED VISION BENEFIT- Access to thousands of providers nationwide, including the leading optical retailers LensCrafters®, Target Optical®, and most Pearle Vision® and Sears Optical® locations. Receive a regular vision exam annually for a $20 copay, in addition to discounts for standard eyeglass lenses, frames and contact lenses. You can also order replacement contacts online and have the contacts mailed to your home. ACCIDENT MEDICAL INSURANCE, ACCIDENTAL DEATH & DISMEMBERMENT (AD&D) INSURANCE- Receive a specified amount (after payment of a $100 deductible per occurrence) for an accident requiring medical care or an accident resulting in death or dismemberment. Not available in all states. This item is underwritten by Zurich National Life Insurance Co.FREQUENTLY ASKED QUESTIONS
Q: Are pre-existing conditions covered by the Limited Benefit Health Insurance?
A: Yes, pre-existing conditions are covered; however, there is a 12-month pre-existing condition limitation on the critical illness benefit only.
Q: Regarding the Insurance benefits, is there a copayment amount? Is there a deductible?
A: There are NO copayments or deductibles associated with the Limited Benefit Health Insurance.
Q: How do I pay for doctor visits or file a claim?
A: At the time of a visit, present your ID card to the provider. The back of your ID card has all the information your provider needs to verify benefits and file claims. Your provider may require the full amount due at the time of service if you are filing your own claim. There are no claim forms necessary. You or your provider should simply send an itemized statement, detailing your medical visit, to the claims address printed on the back of your ID card.
Q: Is maternity covered by the Limited Benefit Health Insurance?
A: Yes, maternity is covered as any other condition.
Q: How do I enroll for coverage?
A: Enrolling in the Limited Benefit Health Insurance is SIMPLE. Just review the information in the Enrollment Guide, choose the level of coverage for you and your family and then complete the enrollment form or call our toll-free enrollment line at 1-866-971-2368 to speak to one of our Customer Service Representatives.
EXCLUSIONS & LIMITATIONS
No coverage shall be provided and no benefits will be paid for any loss resulting in whole or in part from, or contributed to by, or as a natural and probable consequence of any of the following excluded risks.1. suicide or any attempt at suicide or intentionally self-inflicted Injury or any attempt at intentionally self-inflicted Injury or any act of auto-eroticism.
2. travel or flight in or on (including getting in or out of, or on or off of) any vehicle used for aerial navigation, if the Insured Person is:
a. riding as a passenger in any aircraft not intended or licensed for the transportation of passengers;
b. performing, learning to perform or instructing others to perform as a pilot or crew member of any aircraft; or
c. riding as a passenger in an aircraft owned, leased or operated by the Insured Person's employer.
3. declared or undeclared war, or any act of declared or undeclared war.
4. full-time active duty in the armed forces, National Guard or organized reserve corps of any country or international authority. (Unearned premium for any period for which the Insured Person is not covered due to his or her active duty status will be refunded.) (Loss caused while on short-term National Guard or reserve duty for regularly scheduled training purposes is not excluded.).
5. the Insured Person’s being under the influence of narcotics or intoxicants unless administered on the advice of a Physician.
6. the Insured Person’s commission of or attempt to commit a felony.
7. services and supplies which are not prescribed by a Physician as necessary to treat an Injury or Sickness; are received without charge or legal obligation to pay; would not normally be paid in the absence of insurance; are received outside of the United States; or are received while incarcerated by legal authorities of any state or country for any reason.
8. dental treatment unless due to an Injury.
9. cosmetic care, except for reconstructive plastic surgery required as a result of Injury; to restore a normal bodily function; to improve functional impairment by anatomic alteration made as necessary as a result of a congenital birth defect; or for breast reconstruction following mastectomy.
10. any Injury or Sickness covered under any state or federal Worker’s Compensation , Employer’s Liability law or similar law.
11. services and supplies which are not due to an Injury or Sickness except as specifically provided.
12. participating in any sport or sporting activity for wage, compensation, or profit, including officiating or coaching; or racing any type vehicle in an organized event except participating in a Covered Activity.
13. driving any taxi for wage, compensation, or profit.
14. mountaineering using ropes and/or other equipment; parachuting; or hang gliding.
15. custodial care or rest.
16. age of Issue - member cannot exceed 64 years of age. Policy terminates at age of 65.
ACCIDENT MEDICAL GENERAL EXCLUSIONS
A loss shall not be a Covered Loss if it is caused by, contributed to, or resulted from:1. Suicide or any attempt at suicide or intentionally self-inflicted Injury or any attempt at intentionally self-inflicted injury.
2. War or any act of war, whether declared or undeclared.
3. Involvement in any type of active military service.
4. Illness or disease, regardless of how contracted, medical or surgical treatment of illness or disease; or complications following the surgical treatment of illness or disease; except for Accidental ingestion of contaminated foods.
5. Participation in the commission or attempted commission of a crime, any felony, an assault, insurrection or riot.
6. Being intoxicated.
a. A Covered Person will be conclusively presumed to be intoxicated if the level of alcohol in his or her blood exceeds the amount at which a person is presumed, under the law of the locale in which the Accident occurred, to be intoxicated, if operating a motor vehicle.
b. An autopsy report from a licensed medical examiner, law enforcement officer reports, or similar items will be considered proof of the Covered Person’s intoxication.
7. Being under the influence of any prescription drug, controlled substance, or hallucinogen, unless such prescription drug, controlled substance, or hallucinogen was prescribed by a Physician and taken in accordance with the prescribed dosage.
8. Travel or flight in any aircraft except as a fare-paying passenger on a regularly scheduled charter or commercial flight.
9. Release, whether or not Accidental, or by any person unlawfully or intentionally, of nuclear energy or radiation, including sickness or disease resulting from such release.
10. A cardiovascular event or stroke caused by exertion prior to or at the same time as an Accident
11. Any condition for which the Insured is entitled to benefits under any Workers' compensation.